9241546093

8/12/2019 9241546093

http://slidepdf.com/reader/full/9241546093 1/51

Guid

inpati

m

ISBN 92-4-154609-3

Severely malnourished children need special care. This book provides simple,

practical guidelines for treating these children successfully and takes into account

the limited resources of many hospitals and health units in developing countries.

It is intended for doctors, nurses, dietitians and other health workers with

responsibility for the medical and dietary management of severely malnourished

children, and for their trainers and supervisors. The guidelines are authoritativeand hospitals using them report substantial reductions in mortality. For example,

mortality rates of 30-50% have fallen to 5-15%. The instructions are clear, concise,

and easy to follow and the information is consistent with other WHO publications.

The aim is to help improve the quality of inpatient care and so prevent unnecessary

deaths.

The guidelines can be used as a practical ten-step treatment tool, or as additional

support material to a WHO training course on the management of severe malnutrition

in hospital settings.

8/12/2019 9241546093


Guidelines for the inpatient treatment of severely malnourished children 1

Guidelines

for the

inpatient

treatment of

severely

malnourished

children

Authors1

Ann Ashworth

Sultana Khanum

Alan Jackson

Claire Schofield

1Dr Sultana Khanum, former Regional Adviser, Nutrition for Health and Development, WHO South-

East Asia Regional Office

Professor Ann Ashworth & Ms Claire Schofield, London School of Hygiene and Tropical Medicine

Professor Alan Jackson, University of Southampton

World Health Organization

8/12/2019 9241546093


Guidelines for the inpatient treatment of severely malnourished children2

WHO Library Cataloguing-in-Publication Data

Ashworth, Ann.

Guidelines for the inpatient treatment of severely malnourished children /

Ann Ashworth et al.

1. Child nutrition disorders – therapy 2. Starvation – therapy 3. Guidelines

4. Manuals I.Title

ISBN 92 4 154609 3 (NLM classification: WS 115)

© World Health Organization 2003

All rights reserved. Publications of the World Health Organization can be

obtained from Marketing and Dissemination, World Health Organization, 20

Avenue Appia, 1211 Geneva 27, Switzerland (tel: +41 22 791 2476; fax: +41

22 791 4857; email: [email protected]). Requests for permission to

reproduce or translate WHO publications – whether for sale or for

noncommercial distribution – should be addressed to Publications, at the

above address (fax: +41 22 791 4806; email: [email protected]).

The designations employed and the presentation of the material in this

publication do not imply the expression of any opinion whatsoever on thepart of the World Health Organization concerning the legal status of any

country, territory, city or area or of its authorities, or concerning the

delimitation of its frontiers or boundaries. Dotted lines on maps represent

approximate border lines for which there may not yet be full agreement.

The mention of specific companies or of certain manufacturers’ products

does not imply that they are endorsed or recommended by the World Health

Organization in preference to others of a similar nature that are not

mentioned. Errors and omissions excepted, the names of proprietary

products are distinguished by initial capital letters.

The World Health Organization does not warrant that the information

contained in this publication is complete and correct and shall not be liable

for any damages incurred as a result of its use.

The named authors alone are responsible for the views expressed in this

publication.

Printed in

8/12/2019 9241546093



Preface

Acknowledgements

Introduction

A. General principles for routine care (the ‘10 Steps’) 10

Step 1. Treat/prevent hypoglycaemia 11

Step 2. Treat/prevent hypothermia 11

Step 3. Treat/prevent dehydration 12

Step 4. Correct electrolyte imbalance 14

Step 5. Treat/prevent infection 14

Step 6. Correct micronutrient deficiencies 16

Step 7. Start cautious feeding 16

Step 8. Achieve catch-up growth 18

Step 9. Provide sensory stimulation and emotional support 19

Step 10. Prepare for follow-up after recovery 20

B. Emergency treatment of shock and severe anaemia 21

1. Shock in severely malnourished children 21

2. Severe anaemia in malnourished children 22

C. Treatment of associated conditions 23

1. Vitamin A deficiency 23

2. Dermatosis 23

3. Parasitic worms 24

4. Continuing diarrhoea 24

5. Tuberculosis (TB) 24

D. Failure to respond to treatment 25

1. High mortality 25

2. Low weight gain during the rehabilitation phase 25

E. Discharge before recovery is complete 28

Appendix 1. Weight-for-height reference table 30

Appendix 2. Monitoring records 32

Appendix 3. Recipes for ReSoMal & electrolyte/mineral solution 33

Appendix 4. Antibiotics reference table 35

Appendix 5. Recipes for starter and catch-up formulas 38

Appendix 6. Volume of F-75 to give for children of different

weights 40

Appendix 7. Volume of F-75 for children with severe (+++)

oedema 41

Appendix 8. Range of volumes for free feeding with F-100 42

Appendix 9. Weight record chart 43

Appendix 10. Structured play activities 44

Appendix 11. Discharge card 47

Contents

8/12/2019 9241546093



8/12/2019 9241546093



Preface

Poor nutrition severely hinders personal, social and national development.

The problem is more obvious among the poor and disadvantaged. The

ultimate consequence is millions of severely malnourished children throughout

the world. In developing countries an estimated 50.6 million children under

the age of five are malnourished. Some are severely malnourished and

are admitted to hospital but regrettably the death rate during treatment is

as high as 30-50% in some hospitals. With appropriate treatment, as

described in these guidelines, this unacceptably high death rate can be

reduced to less than 5%. The evidence base for effective prevention and

treatment is incontrovertible, but it is not put into practice.

Data from 67 studies worldwide show that the median case fatality rate

has not changed for the past five decades, and that one in four severely

malnourished children died during treatment in the 1990s. In any decade,

however, some centres obtained good results with fewer than 5% dying,

whereas others fared poorly with a mortality rate of approximately 50%.

This disparity is not due to differences in the prevalence of severe cases of

malnutrition, but it is rather the result of poor treatment practices. Where mortality

is low a set of basic principles has been followed. High case fatality rates

and poor rates of weight gain result from a failure to appreciate that treatment

has to be carried out in stages and that the order in which problems are

addressed is fundamental to effective care:

• firstly, severe malnutrition represents a medical emergency with an

urgent need to correct hypothermia, hypoglycaemia and silent infection;

• secondly, there is an impairment of the cellular machinery. Tissue

function cannot be restored unless the machinery is repaired, which

includes remedying multiple specific deficiencies. These may not be

visible, and often are the consequence of multiple silent infections;

• thirdly, tissue deficits and abnormal body composition are obvious,

but cannot be safely corrected until the cellular machinery has been

adequately repaired. Rehydration with intravenous fluids can increase

mortality, as can manipulation of abnormal blood chemistry.

Aggressive attempts to promote rapid weight gain from the start of treatment is also dangerous. Many prescribe a high protein diet for

children with kwashiorkor, but this can be fatal. Many prescribe

diuretics to get rid of oedema. This procedure can be fatal.

Prescribing iron to treat anaemia increases deaths in the initial

phase of treatment.

8/12/2019 9241546093



Substantial reductions in mortality rates have been achieved by modifying

treatment to take account of the physiological and metabolic changes

occurring in severe malnutrition. In the International Centre for Diarrhoeal

Disease Research, Bangladesh, after the introduction of a standardized

protocol, based on the WHO guidelines, case fatality rate decreased to

9% and subsequently to 3.9% from an earlier 17%. In South Africa, the

mortality rate decreased from 30-40% to less than 15%. Emergency

relief organizations successfully use the guidelines to treat severe

malnutrition in tents.The treatment guidelines described here are therefore

applicable not only in hospitals but also in therapeutic feeding centres in

emergency situations, and in nutrition rehabilitation centres after initial

treatment in hospital.

Sultana Khanum

Department of Nutrition for Health and Development


8/12/2019 9241546093



Acknowledgements

The authors gratefully acknowledge the contributions and suggestions of Dr

Graeme Clugston, Dr Djamil Benbouzid, and Dr Olivier Fontaine (WHO,

Geneva), and Professor Michael Golden (University of Aberdeen).

Thanks are due to Professor Sally Grantham-McGregor (Institute of Child

Health) for the play activities, and to Professor John Waterlow, Professor

Joe Millward, Dr Harry Campbell, Ann Burgess and Patricia Whitesell for

their advice and encouragement.

In addition, WHO wishes to thank the Canadian International Development

Agency (CIDA) and the Department for International Development (DFID),

U.K., for providing financial support for the production of this document.

8/12/2019 9241546093



8/12/2019 9241546093



Introduction

Every year some 10.6 million children die before they reach their fifth

birthday. Seven out of every 10 of these deaths are due to diarrhoea,

pneumonia, measles, malaria or malnutrition. The WHO manual

Management of Severe Malnutrition: a manual for physicians and other

senior health workers and the following companion guidelines have been

developed to improve inpatient treatment of severe malnutrition. The WHO/

UNICEF strategy of Integrated Management of Childhood Illness (IMCI)

also aims to reduce these deaths by improving treatment.

Special guidelines are needed because of the profound physiological and

metabolic changes that take place when children become malnourished.

These changes affect every cell, organ and system. The process of change

is called reductive adaptation. Malnourished children do not respond to medical

treatment in the same way as if they were well nourished. Malnourished

children are much more likely to die, with or without complications, than their

well nourished counterparts. With appropriate case management in hospital

and follow-up care, the lives of many children can be saved.

The following guidelines set out simple, specific instructions for the

treatment of severely malnourished children. The aim is to provide practical

help for those responsible for the medical and dietary management of such

children. Lack of appropriate care leads to diarrhoea, poor appetite, slow

recovery and high mortality. These problems can be overcome if certain

basic principles are followed.

Severe malnutrition is defined in these guidelines as the presence of

severe wasting (<70% weight-for-height or <-3SD) and/or oedema

on both feet. (Appendix 1 provides a weight-for-height reference table.)

The guidelines are divided in five sections:

A. General principles for routine care (the’10 steps’)

B. Emergency treatment of shock and severe anaemia

C. Treatment of associated conditions

D. Failure to respond to treatment

E. Discharge before recovery is complete

8/12/2019 9241546093


8/12/2019 9241546093



Step 1. Treat/prevent hypoglycaemia

Hypoglycaemia and hypothermia usually occur together and are signs of

infection. Check for hypoglycaemia whenever hypothermia

(axillary<35.0oC; rectal<35.5oC) is found. Frequent feeding is important in

preventing both conditions.

Treatment:

If the child is conscious and dextrostix shows <3mmol/l or 54mg/dl give:

• 50 ml bolus of 10% glucose or 10% sucrose solution (1 rounded

teaspoon of sugar in 3.5 tablespoons water), orally or by nasogastric

(NG) tube. Then feed starter F-75 (see step 7) every 30 min. for twohours (giving one quarter of the two-hourly feed each time)

• antibiotics (see step 5)

• two-hourly feeds, day and night (see step 7)

If the child is unconscious, lethargic or convulsing give:

• IV sterile 10% glucose (5ml/kg), followed by 50ml of 10% glucose

or sucrose by Ng tube. Then give starter F-75 as above

• antibiotics

• two-hourly feeds, day and night

Monitor:

• blood glucose: if this was low, repeat dextrostix taking blood from

finger or heel, after two hours. Once treated, most children stabilisewithin 30 min. If blood glucose falls to <3 mmol/l give a further 50ml

bolus of 10% glucose or sucrose solution, and continue feeding every

30 min. until stable

• rectal temperature: if this falls to <35.5oC, repeat dextrostix

• level of consciousness: if this deteriorates, repeat dextrostix

Prevention:

• feed two-hourly, start straightaway (see step 7) or if necessary,

rehydrate first

• always give feeds throughout the night

Note: If you are unable to test the blood glucose level, assume all severelymalnourished children are hypoglycaemic and treat accordingly.

8/12/2019 9241546093



Step 2. Treat/prevent hypothermia

Treatment:

If the axillary temperature is <35.0oC, take the rectal temperature using a low

reading thermometer.

If the rectal temperature is <35.5oC (<95.9oF):

• feed straightaway (or start rehydration if needed)

• rewarm the child: either clothe the child (including head), cover with a

warmed blanket and place a heater or lamp nearby (do not use a

hot water bottle), or put the child on the mother’s bare chest (skin to

skin) and cover them• give antibiotics (see step 5)

Monitor:

• body temperature: during rewarming take rectal temperature two-

hourly until it rises to >36.5oC (take half-hourly if heater is used)

• ensure the child is covered at all times, especially at night

• feel for warmth

• blood glucose level: check for hypoglycaemia whenever

hypothermia is found

(Appendix 2 provides an example of a chart for recording temperature, pulse

and respiratory rates).

Prevention:

• feed two-hourly, start straightaway (see step 7)

• always give feeds throughout the day and night

• keep covered and away from draughts

• keep the child dry, change wet nappies, clothes and bedding

• avoid exposure (e.g. bathing, prolonged medical examinations)

• let child sleep with mother/carer at night for warmth

Note: If a low reading thermometer is unavailable and the child’s temperature

is too low to register on an ordinary thermometer, assume the child has

hypothermia.

8/12/2019 9241546093



Step 3. Treat/prevent dehydration

Note: Low blood volume can coexist with oedema. Do not use the IV

route for rehydration except in cases of shock and then do so with care,

infusing slowly to avoid flooding the circulation and overloading the heart

(see Section B: Emergency treatment).

Treatment:

The standard oral rehydration salts solution (90 mmol sodium/l) contains

too much sodium and too little potassium for severely malnourished children.

Instead give special Rehydration Solution for Malnutrition (ReSoMal). (For

recipe see Appendix 3).

It is difficult to estimate dehydration status in a severely malnourished child

using clinical signs alone. So assume all children with watery diarrhoea

may have dehydration and give:

• ReSoMal 5 ml/kg every 30 min. for two hours, orally or by nasogastric

tube, then

• 5-10 ml/kg/h for next 4-10 hours: the exact amount to be given should

be determined by how much the child wants, and stool loss and

vomiting. Replace the ReSoMal doses at 4, 6, 8 and 10 hours with

F-75 if rehydration is continuing at these times, then

• continue feeding starter F-75 (see step 7)

During treatment, rapid respiration and pulse rates should slow down and

the child should begin to pass urine.

Monitor progress of rehydration:

Observe half-hourly for two hours, then hourly for the next 6-12 hours,

recording:

• pulse rate

• respiratory rate

• urine frequency

• stool/vomit frequency

Return of tears, moist mouth, eyes and fontanelle appearing less sunken,and improved skin turgor, are also signs that rehydration is proceeding. It

8/12/2019 9241546093



should be noted that many severely malnourished children will not show

these changes even when fully rehydrated.

Continuing rapid breathing and pulse during rehydration suggest coexisting

infection or overhydration. Signs of excess fluid (overhydration) are

increasing respiratory rate and pulse rate, increasing oedema and puffy

eyelids. If these signs occur, stop fluids immediately and reassess after

one hour.

Prevention:

To prevent dehydration when a child has continuing watery diarrhoea:

• keep feeding with starter F-75 (see step 7)

• replace approximate volume of stool losses with ReSoMal. As a

guide give 50-100 ml after each watery stool. (Note: it is common for

malnourished children to pass many small unformed stools: these

should not be confused with profuse watery stools and do not require

fluid replacement)

• if the child is breastfed, encourage to continue

Step 4. Correct electrolyte imbalance

All severely malnourished children have excess body sodium even though

plasma sodium may be low (giving high sodium loads will kill). Deficienciesof potassium and magnesium are also present and may take at least two

weeks to correct. Oedema is partly due to these imbalances. Do NOT treat

oedema with a diuretic.

Give:

• extra potassium 3-4 mmol/kg/d

• extra magnesium 0.4-0.6 mmol/kg/d

• when rehydrating, give low sodium rehydration fluid (e.g. ReSoMal)

• prepare food without salt

The extra potassium and magnesium can be prepared in a liquid form and

added directly to feeds during preparation. Appendix 3 provides a recipe for

a combined electrolyte/mineral solution. Adding 20 ml of this solution to 1 litreof feed will supply the extra potassium and magnesium required. The solution

can also be added to ReSoMal.

8/12/2019 9241546093



Step 5. Treat/prevent infection

In severe malnutrition the usual signs of infection, such as fever, are often

absent, and infections are often hidden.

Therefore give routinely on admission:

• broad-spectrum antibiotic(s)AND

• measles vaccine if child is > 6m and not immunised

(delay if the child is in shock)

Note: Some experts routinely give, in addition to broad-spectrum

antibiotics, metronidazole (7.5 mg/kg 8-hourly for 7 days) to hasten repair

of the intestinal mucosa and reduce the risk of oxidative damage andsystemic infection arising from the overgrowth of anaerobic bacteria in

the small intestine.

Choice of broad-spectrum antibiotics: (see Appendix 4 for antibiotic

dosage):

a) if the child appears to have no complications give:

• Co-trimoxazole 5 ml paediatric suspension orally twice daily for 5

days (2.5 ml if weight <6 kg). (5 ml is equivalent to 40 mg TMP+200

mg SMX).

ORb) if the child is severely ill (apathetic, lethargic) or has complications

(hypoglycaemia; hypothermia; broken skin; respiratory tract or urinary

tract infection) give:

• Ampicillin 50 mg/kg IM/IV 6-hourly for 2 days, then oral amoxycillin 15

mg/kg 8-hourly for 5 days, or if amoxycillin is not available, continue

with ampicillin but give orally 50 mg/kg 6-hourly

AND

• Gentamicin 7.5 mg/kg IM/IV once daily for 7 days

If the child fails to improve clinically within 48 hours, ADD:

• Chloramphenicol 25 mg/kg IM/IV 8-hourly for 5 days

Where specific infections are identified, ADD:

• specific antibiotics if appropriate

• antimalarial treatment if the child has a positive blood film for malaria

parasites.

8/12/2019 9241546093



If anorexia persists after 5 days of antibiotic treatment, complete a full 10-

day course. If anorexia still persists, reassess the child fully, checking for

sites of infection and potentially resistant organisms, and ensure that vitamin

and mineral supplements have been correctly given.

Step 6. Correct micronutrient deficiencies

All severely malnourished children have vitamin and mineral deficiencies.

Although anaemia is common, doNOT give iron initially but wait until the

child has a good appetite and starts gaining weight (usually by the second

week), as giving iron can make infections worse.

Give:

• Vitamin A orally on Day 1 (for age >12 months, give 200,000 IU; for

age 6-12 months, give 100,000 IU; for age 0-5 months, give 50,000

IU) unless there is definite evidence that a dose has been given in

the last month

Give daily for at least 2 weeks:

• Multivitamin supplement

• Folic acid 1 mg/d (give 5 mg on Day 1)

• Zinc 2 mg/kg/d

• Copper 0.3 mg/kg/d• Iron 3 mg/kg/d but only when gaining weight

Appendix 3 provides a recipe for a combined electrolyte/mineral solution.

Adding 20 ml of this solution to 1 litre of feed will supply the zinc and copper

needed, as well as potassium and magnesium. This solution can also be

added to ReSoMal.

Note: A combined electrolyte/mineral/vitamin mix for severe malnutrition is

available commercially. This can replace the electrolyte/mineral solution

and multivitamin and folic acid supplements mentioned in steps 4 and 6,

but still give the large single dose of vitamin A and folic acid on Day 1, and

iron daily after weight gain has started.

8/12/2019 9241546093



Step 7. Start cautious feeding

In the stabilisation phase a cautious approach is required because of

the child’s fragile physiological state and reduced homeostatic capacity.

Feeding should be started as soon as possible after admission and should

be designed to provide just sufficient energy and protein to maintain basic

physiological processes. The essential features of feeding in the stabilisation

phase are:

• small, frequent feeds of low osmolarity and low lactose

• oral or nasogastric (NG) feeds (never parenteral preparations)

• 100 kcal/kg/d

• 1-1.5 g protein/kg/d• 130 ml/kg/d of fluid (100 ml/kg/d if the child has severe oedema)

• if the child is breastfed, encourage to continue breastfeeding but

give the prescribed amounts of starter formula to make sure the

child’s needs are met.

The suggested starter formula and feeding schedules (see below) are

designed to meet these targets.

Milk-based formulas such as starter F-75 containing 75 kcal/100 ml and 0.9

g protein/100 ml will be satisfactory for most children (see Appendix 5 for

recipes). Give from a cup. Very weak children may be fed by spoon, dropper

or syringe.

A recommended schedule in which volume is gradually increased, and feeding

frequency gradually decreased is:

Days Frequency Vol/kg/feed Vol/kg/d

1-2 2-hourly 11 ml 130 ml

3-5 3-hourly 16 ml 130 ml

6-7+ 4-hourly 22 ml 130 ml

For children with a good appetite and no oedema, this schedule can be

completed in 2-3 days (e.g. 24 hours at each level). Appendix 6 shows the

volume/feed already calculated according to body weight. Appendix 7 givesthe feed volumes for children with severe oedema. Use the Day 1 weight

to calculate how much to give, even if the child loses or gains weight in

this phase.

8/12/2019 9241546093



If, after allowing for any vomiting, intake does not reach 80 kcal/kg/d (105

ml starter formula/kg) despite frequent feeds, coaxing and re-offering, give

the remaining feed by NG tube (see Appendices 6 and 7 (Column 6) for

intake volumes below which NG feeding should be given). Do not exceed

100 kcal/kg/d in this phase.

Monitor and note:

• amounts offered and left over

• vomiting

• frequency of watery stool

• daily body weight

During the stabilisation phase, diarrhoea should gradually diminish and

oedematous children should lose weight. If diarrhoea continues unchecked

despite cautious refeeding, or worsens substantially, see section C4

(continuing diarrhoea).

Step 8. Achieve catch-up growth

In the rehabilitation phase a vigorous approach to feeding is required to

achieve very high intakes and rapid weight gain of >10 g gain/kg/d. Therecommended milk-based F-100 contains 100 kcal and 2.9 g protein/100 ml

(see Appendix 5 for recipes). Modified porridges or modified family foods

can be used provided they have comparable energy and protein

concentrations.

Readiness to enter the rehabilitation phase is signalled by a return of appetite,

usually about one week after admission. A gradual transition is recommended

to avoid the risk of heart failure which can occur if children suddenly consume

huge amounts.

To change from starter to catch-up formula:

• replace starter F-75 with the same amount of catch-up formula F-100 for 48 hours then,

• increase each successive feed by 10 ml until some feed remains

uneaten. The point when some remains unconsumed is likely to

occur when intakes reach about 30 ml/kg/feed (200 ml/kg/d).

8/12/2019 9241546093



Monitor during the transition for signs of heart failure:

• respiratory rate

• pulse rate

If respirations increase by 5 or more breaths/min and pulse by 25 or more

beats/min for two successive 4-hourly readings, reduce the volume per

feed (give 4-hourly F-100 at 16 ml/kg/feed for 24 hours, then 19 ml/kg/feed

for 24 hours, then 22 ml/kg/feed for 48 hours, then increase each feed by

10 ml as above).

After the transition give:

• frequent feeds (at least 4-hourly) of unlimited amounts of a catch-

up formula

• 150-220 kcal/kg/d

• 4-6 g protein/kg/d

• if the child is breastfed, encourage to continue (Note: breast milk does

not have sufficient energy and protein to support rapid catch-up

growth).

See Appendix 8 for range of volumes for free feeding with F-100.

Monitor progress after the transition by assessing the rate of weight

gain:

• weigh child each morning before feeding. Plot weight (Appendix 9

provides example)

• each week calculate and record weight gain as g/kg/d3

If weight gain is:

• poor (<5 g/kg/d), child requires full reassessment (see Section D)

• moderate (5-10 g/kg/d), check whether intake targets are being met,

or if infection has been overlooked

• good (>10 g/kg/d), continue to praise staff and mothers

3 Calculating weight gain :

The example is for weight gain over 7 days, but the same procedure can be applied to any interval:

* substract from today’s weight (in g) the child’s weight 7 days earlier ;

* divide by 7 to determine the average daily weight gain (g/day) ;* divide by the child’s average weight in kg to calculate the weight gain as g/kg/day.

8/12/2019 9241546093



Step 9. Provide sensory stimulation and emotional

support

In severe malnutrition there is delayed mental and behavioural development.

Provide:

• tender loving care

• a cheerful, stimulating environment

• structured play therapy 15-30 min/d (Appendix 10 provides examples)

• physical activity as soon as the child is well enough

• maternal involvement when possible (e.g. comforting, feeding, bathing,

play)

Step 10. Prepare for follow-up after recovery

A child who is 90% weight-for-length (equivalent to -1SD) can be considered

to have recovered. The child is still likely to have a low weight-for-age because

of stunting. Good feeding practices and sensory stimulation should be

continued at home. Show parent or carer how to:

• feed frequently with energy- and nutrient-dense foods

• give structured play therapy

Advise parent or carer to:

• bring child back for regular follow-up checks

• ensure booster immunizations are given

• ensure vitamin A is given every six months

Appendix 11 provides an example of a Discharge Card.

8/12/2019 9241546093



B. EMERGENCY TREATMENT OF SHOCK AND

SEVERE ANAEMIA

1. Shock in severely malnourished children

Shock from dehydration and sepsis are likely to coexist in severely

malnourished children. They are difficult to differentiate on clinical signs alone.

Children with dehydration will respond to IV fluids. Those with septic shock

and no dehydration will not respond. The amount of fluid given is determined

by the child’s response. Overhydration must be avoided.

To start treatment:

• give oxygen

• give sterile 10% glucose (5 ml/kg) by IV

• give IV fluid at 15 ml/kg over 1 hour. Use Ringer’s lactate with 5%

dextrose; or half-normal saline with 5% dextrose; or half-strength

Darrow’s solution with 5% dextrose; or if these are unavailable,

Ringer’s lactate

• measure and record pulse and respiration rates every 10 minutes

• give antibiotics (see step 5)

If there are signs of improvement (pulse and respiration rates fall):• repeat IV 15 ml/kg over 1 hour; then

• switch to oral or nasogastric rehydration with ReSoMal, 10 ml/kg/h

for up to 10 hours. (Leave IV in place in case required again); Give

ReSoMal in alternate hours with starter F-75, then

• continue feeding with starter F-75

If the child fails to improve after the first hour of treatment (15 ml/kg),

assume that the child has septic shock. In this case:

• give maintenance IV fluids (4 ml/kg/h) while waiting for blood,

• when blood is available transfuse fresh whole blood at 10 ml/kg

slowly over 3 hours; then

• begin feeding with starter F-75 (step 7)

8/12/2019 9241546093



If the child gets worse during treatment (breathing increases by 5 breaths

or more/min and pulse increases by 25 or more beats/min):

• stop the infusion to prevent the child’s condition worsening

2. Severe anaemia in malnourished children

A blood transfusion is required if:

• Hb is less than 4 g/dl

• or if there is respiratory distress and Hb is between 4 and 6 g/dl

Give:

• whole blood 10 ml/kg body weight slowly over 3 hours• furosemide 1 mg/kg IV at the start of the transfusion

It is particularly important that the volume of 10 ml/kg is not exceeded in

severely malnourished children. If the severely anaemic child has signs of

cardiac failure, transfuse packed cells (5-7 ml/kg) rather than whole blood.

Monitor for signs of transfusion reactions. If any of the following signs develop

during the transfusion, stop the transfusion:

• fever

• itchy rash

• dark red urine

• confusion• shock

Also monitor the respiratory rate and pulse rate every 15 minutes. If either of

them rises, transfuse more slowly. Following the transfusion, if the Hb remains

less than 4 g/dl or between 4 and 6 g/dl in a child with continuing respiratory

distress, DO NOT repeat the transfusion within 4 days. In mild or moderate

anaemia, oral iron should be given for two months to replenish iron stores

BUT this should not be started until the child has begun to gain weight.

8/12/2019 9241546093



C. TREATMENT OF ASSOCIATED CONDITIONS

Treatment of conditions commonly associated with severe malnutrition:

1. Vitamin A deficiency

If the child shows any eye signs of deficiency, give orally:

• vitamin A on days 1, 2 and 14 (for age >12 months, give 200,000 IU;

for age 6-12 months, give 100,000 IU; for age 0-5 months, give

50,000 IU). If first dose has been given in the referring centre, treat

on days 1 and 14 only

If there is corneal clouding or ulceration, give additional eye care to

prevent extrusion of the lens:

• instil chloramphenicol or tetracycline eye drops (1%) 2-3 hourly as

required for 7-10 days in the affected eye

• instil atropine eye drops (1%), 1 drop three times daily for 3-5 days

• cover with eye pads soaked in saline solution and bandage

Note: children with vitamin A deficiency are likely to be photophobic and

have closed eyes. It is important to examine the eyes very gently to prevent

rupture.

2. DermatosisSigns:

• hypo-or hyperpigmentation

• desquamation

• ulceration (spreading over limbs, thighs, genitalia, groin, and behind

the ears)

• exudative lesions (resembling severe burns) often with secondary

infection, including Candida

Zinc deficiency is usual in affected children and the skin quickly improves

with zinc supplementation (see step 6). In addition:

• apply barrier cream (zinc and castor oil ointment, or petroleum jellyor paraffin gauze) to raw areas

• omit nappies so that the perineum can dry

8/12/2019 9241546093



3. Parasitic worms

• give mebendazole 100 mg orally, twice daily for 3 days

4. Continuing diarrhoea

Diarrhoea is a common feature of malnutrition but it should subside during

the first week of treatment with cautious feeding. In the rehabilitation phase,

loose, poorly formed stools are no cause for concern provided weight gain is

satisfactory.

Mucosal damage and giardiasis are common causes of continuing

diarrhoea. Where possible examine the stools by microscopy. Give:

• metronidazole (7.5 mg/kg 8-hourly for 7 days) if not already given

Lactose intolerance. Only rarely is diarrhoea due to lactose intolerance.

Treat only if continuing diarrhoea is preventing general improvement. Starter

F-75 is a low-lactose feed. In exceptional cases:

• substitute milk feeds with yoghurt or a lactose-free infant formula

• reintroduce milk feeds gradually in the rehabilitation phase

Osmotic diarrhoea may be suspected if diarrhoea worsens substantially

with hyperosmolar starter F-75 and ceases when the sugar content is

reduced and osmolarity is <300 mOsmol/l. In these cases:

• use isotonic F-75 or low osmolar cereal-based F-75 (see Appendix 5

for recipe)

• introduce F-100 gradually

5. Tuberculosis (TB)

If TB is strongly suspected (contacts with adult TB patient, poor growth

despite good intake, chronic cough, chest infection not responding to

antibiotics):

• perform Mantoux test (false negatives are frequent)

• chest X-ray if possible

If test is positive or there is a strong suspicion of TB, treat according to

national TB guidelines.

8/12/2019 9241546093



D. FAILURE TO RESPOND TO TREATMENT

Failure to respond is indicated by:

1. High mortality

Case fatality rates vary widely: >20% should be considered unacceptable,

11-20% poor, 5-10% moderate, and <5% good.

If mortality is >5%, determine whether the majority of deaths occur:

• within 24 hours: consider untreated or delayed treatment of

hypoglycaemia, hypothermia, septicaemia, severe anaemia or

incorrect rehydration fluid or volume

• within 72 hours: check whether the volume of feed is too high or the

wrong formulation is used

• at night: consider hypothermia from insufficient covers, no night feeds

• when changing to catch-up F-100: consider too rapid a transition

2. Low weight gain during the rehabilitation phase

Poor: <5g/kg/d

Moderate: 5-10g/kg/d

Good: >10 g/kg/d

If weight gain is <5 g/kg/d determine:

• whether this is for all cases (need major management overhaul)

• whether this is for specific cases (reassess child as for a new

admission)

Possible causes of poor weight gain are:

a) Inadequate feeding

Check:

• that night feeds are given

• that target energy and protein intakes are achieved: is actual intake

(offered minus leftovers) correctly recorded? Is the quantity of feedrecalculated as the child gains weight? Is the child vomiting or

ruminating?

8/12/2019 9241546093



• feeding technique: is the child fed frequently and offered unlimited

amounts?

• quality of care: are staff motivated/gentle/loving/patient?

• all aspects of feed preparation: scales, measurement of ingredients,

mixing, taste, hygienic storage, adequate stirring if the ingredients

separate out

• that if giving family foods, they are suitably modified to provide >100

kcal/100g (if not, re-modify). If resources for modification are limited, or

children are not inpatients, compensate by replacing F-100 with catch-

up F-135 containing 135 kcal/100ml (see Appendix 5 for recipe)

b) Specific nutrient deficiencies

Check:

• adequacy of multivitamin composition and shelf-life

• preparation of electrolyte/mineral solution and whether this is correctly

prescribed and administered. If in goitrous region, check potassium

iodide (KI) is added to the electrolyte/mineral solution (12 mg/2500 ml)

or give all children Lugol’s iodine (5-10 drops/day)

• that, if modified family foods are substantially replacing F-100, electrolyte/

mineral solution is added to the family food (20 ml/day)

c) Untreated infection

If feeding is adequate and there is no malabsorption, some hidden infection

can be suspected. Urinary tract infections, otitis media, TB and giardiasis

are easily overlooked, hence

• re-examine carefully

• repeat urinalysis for white blood cells

• examine stools

• if possible, take chest X-ray

Alter the antibiotic schedule (step 5) only if a specific infection is identified.

d) HIV/AIDS

In children with HIV/AIDS, good recovery from malnutrition is possible

though it may take longer and treatment failures may be common. Lactose

intolerance occurs in severe HIV-related chronic diarrhoea. Treatment should

be the same as for HIV negative children.

8/12/2019 9241546093



e) Psychological problems

Check for:

• abnormal behaviour such as stereotyped movements (rocking),

rumination (self-stimulation through regurgitation) and attention seeking

Treat by giving the child extra care, love and attention. For the ruminator,

firmness, but with affection and without intimidation, can assist.

8/12/2019 9241546093



E. DISCHARGE BEFORE RECOVERY IS COMPLETE

A child may be considered to have recovered and be ready for discharge

when she/he reaches 90% weight-for-length. For some children, earlier

discharge may be considered if effective alternative supervision is available.

Domiciliary care or home-based treatment should be considered only if the

following criteria are met:

The child

• is aged >12 months

• has completed antibiotic treatment

• has good appetite and good weight gain• has taken potassium/magnesium/mineral/vitamin supplement for 2

weeks (or continuing supplementation at home is possible)

The mother/carer

• is not employed outside the home

• is specifically trained to give appropriate feeding (type, amount and

frequency)

• has the financial resources to feed the child

• lives within easy reach of the hospital for urgent readmission if the

child becomes ill

• can be visited weekly

• is trained to give structured play therapy• is motivated to follow the advice given

Local health workers

• are trained to support home care

• are specifically trained to examine the child clinically at home, to decide

when to refer him/her back to hospital, to weigh the child, and give

appropriate advice

• are motivated

When children are being rehabilitated at home, it is essential to give

frequent meals with a high energy and protein content. Aim at achieving

at least 150 kcal/kg/d and adequate protein intake (at least 4 g/kg/d).This means feeding the child at least 5 times per day with foods that

8/12/2019 9241546093



contain approximately 100 kcal and 2-3 g protein per 100 g. A practical

approach would be using simple modifications of the usual home foods.

Vitamin, iron and electrolyte/mineral supplements can be continued at

home. The carer should be shown how to:

• give appropriate meals at least 5 times daily

• give high energy snacks between meals (e.g. milk, banana, bread,

biscuits, peanutbutter)

• assist and encourage the child to complete each meal

• give electrolyte and micronutrient supplements. Give 20 ml (4

teaspoons) of the electrolyte/mineral solution daily. Since it tastes

unpleasant, it will probably need to be masked in porridge, or milk

(one teaspoon/200 ml fluid)

• breastfeed as often as the child wants

Further reading:

• World Health Organization, Management of severe malnutrition: a

manual for physicians and other senior health workers. Geneva:

World Health Organization, 1999.

• World Health Organization, Management of the child with a serious

infection or severe malnutrition: guidelines for care at the first-referral

level in developing countries. Geneva: World Health Organization,

2000 (WHO/FCH/CAH/00.1).

8/12/2019 9241546093



Appendix 1

Weight-for-Height Reference TableBoys’ weight (kg) Lengtha(cm) Girls’ weight (kg)

-4 SDb -3 SD -2 SD -1 SD Median Median -1SD -2SD -3 SD -4 SD

(60%) (70%) (80%) (90%) (90%) (80%) (70%) (60%)

1.8 2.1 2.5 2.8 3.1 49 3.3 2.9 2.6 2.2 1.8

1.8 2.2 2.5 2.9 3.3 50 3.4 3.0 2.6 2.3 1.9

1.8 2.2 2.6 3.1 3.5 51 3.5 3.1 2.7 2.3 1.9

1.9 2.3 2.8 3.2 3.7 52 3.7 3.3 2.8 2.4 2.0

1.9 2.4 2.9 3.4 3.9 53 3.9 3.4 3.0 2.5 2.1

2.0 2.6 3.1 3.6 4.1 54 4.1 3.6 3.1 2.7 2.2

2.2 2.7 3.3 3.8 4.3 55 4.3 3.8 3.3 2.8 2.3

2.3 2.9 3.5 4.0 4.6 56 4.5 4.0 3.5 3.0 2.4

2.5 3.1 3.7 4.3 4.8 57 4.8 4.2 3.7 3.1 2.6

2.7 3.3 3.9 4.5 5.1 58 5.0 4.4 3.9 3.3 2.7

2.9 3.5 4.1 4.8 5.4 59 5.3 4.7 4.1 3.5 2.9

3.1 3.7 4.4 5.0 5.7 60 5.5 4.9 4.3 3.7 3.1

3.3 4.0 4.6 5.3 5.9 61 5.8 5.2 4.6 3.9 3.3

3.5 4.2 4.9 5.6 6.2 62 6.1 5.4 4.8 4.1 3.5

3.8 4.5 5.2 5.8 6.5 63 6.4 5.7 5.0 4.4 3.7

4.0 4.7 5.4 6.1 6.8 64 6.7 6.0 5.3 4.6 3.9

4.3 5.0 5.7 6.4 7.1 65 7.0 6.3 5.5 4.8 4.1

4.5 5.3 6.0 6.7 7.4 66 7.3 6.5 5.8 5.1 4.3

4.8 5.5 6.2 7.0 7.7 67 7.5 6.8 6.0 5.3 4.5

5.1 5.8 6.5 7.3 8.0 68 7.8 7.1 6.3 5.5 4.8

5.3 6.0 6.8 7.5 8.3 69 8.1 7.3 6.5 5.8 5.0

5.5 6.3 7.0 7.8 8.5 70 8.4 7.6 6.8 6.0 5.2

5.8 6.5 7.3 8.1 8.8 71 8.6 7.8 7.0 6.2 5.46.0 6.8 7.5 8.3 9.1 72 8.9 8.1 7.2 6.4 5.6

6.2 7.0 7.8 8.6 9.3 73 9.1 8.3 7.5 6.6 5.8

6.4 7.2 8.0 8.8 9.6 74 9.4 8.5 7.7 6.8 6.0

6.6 7.4 8.2 9.0 9.8 75 9.6 8.7 7.9 7.0 6.2

6.8 7.6 8.4 9.2 10.0 76 9.8 8.9 8.1 7.2 6.4

7.0 7.8 8.6 9.4 10.3 77 10.0 9.1 8.3 7.4 6.6

7.1 8.0 8.8 9.7 10.5 78 10.2 9.3 8.5 7.6 6.7

7.3 8.2 9.0 9.9 10.7 79 10.4 9.5 8.7 7.8 6.9

7.5 8.3 9.2 10.1 10.9 80 10.6 9.7 8.8 8.0 7.1

7.6 8.5 9.4 10.2 11.1 81 10.8 9.9 9.0 8.1 7.2

7.8 8.7 9.6 10.4 11.3 82 11.0 10.1 9.2 8.3 7.4

7.9 8.8 9.7 10.6 11.5 83 11.2 10.3 9.4 8.5 7.6

8.1 9.0 9.9 10.8 11.7 84 11.4 10.5 9.6 8.7 7.7

7.8 8.9 9.9 11.0 12.1 85 11.8 10.8 9.7 8.6 7.67.9 9.0 10.1 11.2 12.3 86 12.0 11.0 9.9 8.8 7.7

8.1 9.2 10.3 11.5 12.6 87 12.3 11.2 10.1 9.0 7.9

a Length is measured for children below 85 cm. For children 85 cm or more, height is measured. Recumbent length is on

average 0.5 cm greater than standing height; although the difference is of no importance to individual children, a correction may

be made by subtracting 0.5 cm from all lengths above 84.9 cm if standing height cannot be measured.b SD: standard deviation score (or Z-score). Although the interpretation of a fixed percent-of-median value varies across age

and height, and although generally the two scales cannot be compared, the approximate percent-of-median values for –1 and –2

SD are 90% and 80% of median, respectively (Gorstein J et al. Issues in the assessment of nutritional status using

anthropometry . Bulletin of the World Health Organization, 1994, 72:273-283).

8/12/2019 9241546093



Weight-for-Height Reference TableBoys’ weight (kg) Lengtha(cm) Girls’ weight (kg)

-4 SDb -3 SD -2 SD -1 SD Median Median -1SD -2SD -3 SD -4 SD

(60%) (70%) (80%) (90%) (90%) (80%) (70%) (60%)

8.3 9.4 10.5 11.7 12.8 88 12.5 11.4 10.3 9.2 8.1

8.4 9.6 10.7 11.9 13.0 89 12.7 11.6 10.5 9.3 8.2

8.6 9.8 10.9 12.1 13.3 90 12.9 11.8 10.7 9.5 8.4

8.8 9.9 11.1 12.3 13.5 91 13.2 12.0 10.8 9.7 8.5

8.9 10.1 11.3 12.5 13.7 92 13.4 12.2 11.0 9.9 8.7

9.1 10.3 11.5 12.8 14.0 93 13.6 12.4 11.2 10.0 8.8

9.2 10.5 11.7 13.0 14.2 94 13.9 12.6 11.4 10.2 9.0

9.4 10.7 11.9 13.2 14.5 95 14.1 12.9 11.6 10.4 9.1

9.6 10.9 12.1 13.4 14.7 96 14.3 13.1 11.8 10.6 9.3

9.7 11.0 12.4 13.7 15.0 97 14.6 13.3 12.0 10.7 9.5

9.9 11.2 12.6 13.9 15.2 98 14.9 13.5 12.2 10.9 9.6

10.1 11.4 12.8 14.1 15.5 99 15.1 13.8 12.4 11.1 9.8

10.3 11.6 13.0 14.4 15.7 100 15.4 14.0 12.7 11.3 9.9

10.4 11.8 13.2 14.6 16.0 101 15.6 14.3 12.9 11.5 10.1

10.6 12.0 13.4 14.9 16.3 102 15.9 14.5 13.1 11.7 10.3

10.8 12.2 13.7 15.1 16.6 103 16.2 14.7 13.3 11.9 10.5

11.0 12.4 13.9 15.4 16.9 104 16.5 15.0 13.5 12.1 10.6

11.2 12.7 14.2 15.6 17.1 105 16.7 15.3 13.8 12.3 10.8

11.4 12.9 14.4 15.9 17.4 106 17.0 15.5 14.0 12.5 11.0

11.6 13.1 14.7 16.2 17.7 107 17.3 15.8 14.3 12.7 11.2

11.8 13.4 14.9 16.5 18.0 108 17.6 16.1 14.5 13.0 11.4

12.0 13.6 15.2 16.8 18.3 109 17.9 16.4 14.8 13.2 11.6

12.2 13.8 15.4 17.1 18.7 110 18.2 16.6 15.0 13.4 11.9

12.5 14.1 15.7 17.4 19.0 111 18.6 16.9 15.3 13.7 12.1

12.7 14.4 16.0 17.7 19.3 112 18.9 17.2 15.6 14.0 12.312.9 14.6 16.3 18.0 19.6 113 19.2 17.5 15.9 14.2 12.6

13.2 14.9 16.6 18.3 20.0 114 19.5 17.9 16.2 14.5 12.8

13.5 15.2 16.9 18.6 20.3 115 19.9 18.2 16.5 14.8 13.0

13.7 15.5 17.2 18.9 20.7 116 20.3 18.5 16.8 15.0 13.3

14.0 15.8 17.5 19.3 21.1 117 20.6 18.9 17.1 15.3 13.6

14.3 16.1 17.9 19.6 21.4 118 21.0 19.2 17.4 15.6 13.8

14.6 16.4 18.2 20.0 21.8 119 21.4 19.6 17.7 15.9 14.1

14.9 16.7 18.5 20.4 22.2 120 21.8 20.0 18.1 16.2 14.3

15.2 17.0 18.9 20.7 22.6 121 22.2 20.3 18.4 16.5 14.6

15.5 17.4 19.2 21.1 23.0 122 22.7 20.7 18.8 16.8 14.9

15.8 17.7 19.6 21.5 23.4 123 23.1 21.1 19.1 17.1 15.1

16.1 18.0 20.0 21.9 23.9 124 23.6 21.6 19.5 17.4 15.4

16.4 18.4 20.4 22.3 24.3 125 24.1 22.0 19.9 17.8 15.6

16.7 18.7 20.7 22.8 24.8 126 24.6 22.4 20.2 18.1 15.9

17.0 19.1 21.1 23.2 25.2 127 25.1 22.9 20.6 18.4 16.2

17.3 19.4 21.5 23.6 25.7 128 25.7 23.3 21.0 18.7 16.417.6 19.8 21.9 24.1 26.2 129 26.2 23.8 21.4 19.0 16.7

17.9 20.1 22.3 24.5 26.8 130 26.8 24.3 21.8 19.4 16.9

a Length is measured for children below 85 cm. For children 85 cm or more, height is measured. Recumbent length is on

average 0.5 cm greater than standing height; although the difference is of no importance to individual children, a correction may

be made by subtracting 0.5 cm from all lengths above 84.9 cm if standing height cannot be measured.b SD: standard deviation score (or Z-score). Although the interpretation of a fixed percent-of-median value varies across age

and height, and although generally the two scales cannot be compared, the approximate percent-of-median values for –1 and –2

SD are 90% and 80% of median, respectively (Gorstein J et al. Issues in the assessment of nutritional status using

anthropometry . Bulletin of the World Health Organization, 1994, 72:273-283).

8/12/2019 9241546093



Appendix 2

Monitoring records (temperature, respiratoryrate, and pulse rate)

M o n i t o r r e s p i r a t o r y r a t e , p u l s e r a t e a n d t e m p e r a t u r e 2 - 4 h o u

r l y u n t i l a f t e r t r a n s i t i o n

t o F - 1 0 0 a n d p a t i e n t i s s

t a b l e . T h e n m o n i t o r i n g m a y b e l e s s f r e q u e n t ( e . g . , t w i c e d a i l y )

D a n g e r S i g n s : W a t c h f o r i n c r e a s i n g p u l s e a n d r e s p i r a t i o n s , f a s t o r d i f f i c u l t b r e a t h i n

g , s u d d e n i n c r e a s e o r

d e c r e a s e i n

t e m p e r a t u r e , r e c t a l t e m p e r a t u r e b e l o w 3 5 . 5 ° C , a n d o t h e r c h a n g e s i n c o n

d i t i o n .

8/12/2019 9241546093



Appendix 3

Recipes for ReSoMal & electrolyte / mineralsolution

Recipe for ReSoMal oral rehydration solution

Ingredient Amount

Water (boiled & cooled) 2 litres

WHO-ORS One 1 litre-packet*

Sugar 50 g

Electrolyte/mineral solution (see below) 40 ml

ReSoMal contains approximately 45 mmol Na, 40 mmol K and 3 mmol Mg/

litre.

Recipe for Electrolyte/mineral solution (used in the

preparation of ReSoMal and milk feeds)

Weigh the following ingredients and make up to 2500 ml. Add 20 ml of

electrolyte/mineral solution to 1000 ml of milk feed.

quantity g molar content of 20 ml

Potassium Chloride: KCl 224 24 mmol

Tripotassium Citrate: C6H

5K

3O

7.H

2O 81 2 mmol

Magnesium Chloride: MgCl2.6H

2O 76 3 mmol

Zinc Acetate: Zn(CH3COO)

2.2H

20 8.2 300 µmol

Copper Sulphate: CuSO4.5H

2O 1.4 45 µmol

Water: make up to 2500 ml

Note: add selenium if available (sodium selenate 0.028 g, NaSeO4 10H

20)

and iodine (potassium iodide 0.012g, KI) per 2500 ml.

* 3.5g sodium chloride, 2.9g trisodium citrate dihydrate, 1.5g potassium chloride, 20g glucose.

8/12/2019 9241546093



Preparation: Dissolve the ingredients in cooled boiled water. Store the

solution in sterilised bottles in the fridge to retard deterioration. Discard if

it turns cloudy. Make fresh each month.

If the preparation of this electrolyte/mineral solution is not possible and if pre-

mixed sachets (see step 4) are not available, give K, Mg and Zn separately.

Potassium:• Make a 10% stock solution of potassium chloride (100 g KCl in 1 litre

of water):

• For oral rehydration solution, use 45 ml of stock KCl solution instead

of 40 ml electrolyte/mineral solution

• For milk feeds, add 22.5 ml of stock KCl solution instead of 20 ml

of the electrolyte/mineral solution

• If KCl is not available, give Slow K (½ crushed tablet/kg/day)

Magnesium:

• Give 50% magnesium sulphate intramuscularly once (0.3 ml/kg up to

a maximum of 2 ml)

Zinc:

• Make a 1.5% solution of zinc acetate (15 g zinc acetate in 1 litre of

water). Give the 1.5% zinc acetate solution orally, 1 ml/kg/day

8/12/2019 9241546093



Appendix 4

Antibiotics reference table

Summary: Antibiotics for Severely Malnourished

Children

IF: GIVE:

NO COMPLICATIONS Cotrimoxazole oral (25 mg sulfamethoxazole

+ 5 mg trimethoprim / kg) every 12 hours for 5

days

COMPLlCATIONS Gentamicin1 IV or IM (7.5 mg/kg), once daily

(shock, hypoglycaemia, for 7 days, plus:

hypothermia, dermatosis

with raw skin/fissures, Ampicillin IV or Followed by: Amoxicillin2

respiratory or urinary tract IM (50 mg/kg), oral (15 mg/kg), every

infections, or lethargic/sickly every 6 hours for 2 8 hours for 5 days

appearance) days

If child fails to improve within Chloramphenicol IV or IM (25 mg/kg), every

48 hours, ADD: 8 hours for 5 days (give every 6 hours if

meningitis is suspected.)

If a specific infection Specific antibiotic as directed on pages

requires an additional 30 - 33 of the manual Management of Severe

antibiotic, Malnutrition

1 If the child is not passing urine, gentamicin may accumulate in the body and cause deafness. Do

not give the second dose until the child is passing urine.2 If amoxicillin is not available, give ampicillin, 50 mg/kg orally every 6 hours for 5 days.

8/12/2019 9241546093



Doses for specific formulations and body

weight ranges

ROUTE/DOSE/

FREQUENCY/

DURATION

ANTIBIOTIC

DOSE ACCORDING TO CHILD’S WEIGHT

Oral: 15 mg/kg

every 8 hours

for 5 days

Oral: 50 mg/kg

every 6 hoursfor 5 days

IV/IM: 50 mg/kg

every 6 hours

for 2 days

Oral: 25mg SMX +

5mgTMP/kg every

12 hours for 5 days

Oral: 7.5 mg/kg

every 8 hours

for 7 days

Oral: 15 mg/kg

every 6 hours

for 5 days

IV or IM:

50 000 units/kg

every 6 hours

for 5 days

Amoxicillin

Ampicillin

Cotrimoxazole

sulfamethoxazole

+ trimethoprim,

SMX + TMP

Metronidazole

Nalidixic Acid

Benzylpenicillin

3 up to 6kg 6 up to 8kg 8 up to 10kg

1/4 tablet 1/2 tablet 1/2 tablet

2.5 ml 5 ml 5 ml

1.5 ml 2 ml 2.5 ml

Tablet, 250 mg

Syrup, 125 mg/5ml

Syrup, 250 mg/5ml

FORMULATION

Tablet, 250 mg

Vial of 500 mg mixed with

2.1 ml sterile water to

give 500 mg/2.5 ml

Tablet,

100 mg SMX + 20mg TMP

Syrup, 200 mg SMX

+ 40 mg TMP per 5 ml

Tablet, 250 mg

IV: Vial of 600 mg mixed

with 9.6 ml sterile water to

give 1 000 000 units/

10 ml

IM: Vial of 600 mg mixed

with 1.6 ml sterile water to

give 1 000 000 units/

2 ml

Suspension,

200 mg/5ml

1 tablet 1 1/2 tablet 2 tablets

1 ml 1.75 ml 2.25 ml

2 ml 3.5 ml 4.5 ml

0.4 ml 0.7 ml 0.9 ml

1/4 tablet 1/2 tablet 1/2 tablet

1 ml 1.25 ml 1.5 ml

1 tablet 1 1/2 tablet 2 tablets

2.5 ml 4 ml 5 ml

8/12/2019 9241546093



Doses for selected antibiotics, for specific

formulations and body weights

Weight of child Dose of iron syrup: ferrous fumarate

100 mg/5 ml (20 mg elemental iron per ml)

3 - 6 kg 0.5 ml 6 - 10 kg 0.75 ml

10 - 15 kg 1 ml

Doses for iron syrup for a common formulation

ROUTE DOSE ACCORDING TO CHILD’S WEIGHT

ANTIBIOTIC DOSE/ FORMULATION (use closest weight)

FREQUENCY/

DURATION 3 kg 4 kg 5 kg 6 kg 7 kg 8 kg 9 kg 10 kg 11 kg 12 kg

Chloramphenicol IV or IM: IV: vial of 1 g

25 mg/kg mixed with 9.2 ml 0.75 1 1.25 1.5 1.75 2 2.25 2.5 2.75 3

every 8 hours sterile water to

(or every give 1 g/10 ml

6 hours

if suspect of IM: vial of 1 gmeningitis) mixed with 3.2 ml 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 1.1 1.2

for 5 days ster ile water to

give 1 g/4 ml

Gentamicin IV or IM: IV/IM: vial

7.5 mg/kg containing 20 mg 2.25 3 3.75 4.5 5.25 6 6.75 7.5 8.25 9

once daily (2 ml at 10 mg/ml),

for 7 days undiluted

IV/IM: vial

containing 80 mg 2.25 3 3.75 4.5 5.25 6 6.75 7.5 8.25 9

(2 ml at 40 mg/ml),

mixed with 6 ml

sterile water to

give 80 mg/8ml

IV/IM: vialcontaining 80 mg 0.5 0.75 0.9 1.1 1.3 1.5 1.7 1.9 2 2.25

(2 ml at 40 mg/ml),

undiluted

8/12/2019 9241546093



Appendix 5

Recipes for starter and catch-up formulas

Preparation:

• using an electric blender: place some of the warm boiled water in

the blender, add the milk powder, sugar, oil and electrolyte/mineral

solution. Make up to 1000 ml, and blend at high speed

• if no electric blender is available, mix the milk, sugar, oil and electrolyte/

mineral solution to a paste, and then slowly add the rest of the warm

boiled water and whisk vigorously with a manual whisk• store made-up formula in refrigerator - when possible.

* Alternative recipes using full-cream dried milk or liquid cow’s milk are given on p.39.

F-75 F-100 F-135

(starter) (catch-up) (catch-up)

Dried skimmed milk (g)* 25 80 90

Sugar (g) 100 50 65

Vegetable oil (g) 30 (or 35 ml) 60 (or 70 ml) 85 (or 95 ml)

Electrolyte/mineral

solution (ml) 20 20 20

Water: make up to 1000 ml 1000 ml 1000 ml

Contents per 100 ml

Energy (kcal) 75 100 135

Protein (g) 0.9 2.9 3.3

Lactose (g) 1.3 4.2 4.8

Potassium (mmol) 4.0 6.3 7.7

Sodium (mmol) 0.6 1.9 2.2

Magnesium (mmol) 0.43 0.73 0.8

Zinc (mg) 2.0 2.3 3.0

Copper (mg) 0.25 0.25 0.34

% energy from protein 5 12 10

% energy from fat 36 53 57Osmolarity (mOsmol/1) 413 419 508

8/12/2019 9241546093



F-75 starter formulas

• full-cream dried milk 35 g, 100 g sugar, 20 g (or ml) oil, 20 ml electrolyte/

mineral solution, and make up to 1000 ml

• full-cream cow’s milk (fresh or long life) 300 ml, 100 g sugar, 20 g (or

ml) oil, 20 ml electrolyte/mineral solution and make up to 1000 ml

F-100 catch-up formulas

• full-cream dried milk 110 g, 50 g sugar, 30 g (or ml) oil, 20 ml electrolyte/

mineral solution, and make up to 1000 ml

• full-cream cow’s milk (fresh or long life) 880 ml, 75 g sugar, 20 g (or ml)

oil, 20 ml electrolyte/mineral solution and make up to 1000 ml

F-135 catch-up formulas

This is for use in special circumstances (see Section D2, poor

weight gain) for children aged > 6 months

• full-cream dried milk 130 g, 70 g sugar, 40 g (or 45 ml) oil, 20 mlelectrolyte/mineral solution, make up to 1000 ml

• full-cream cow’s milk (fresh or long life) 880 ml, 50 g sugar, 60 g (or 65

ml) oil, 20 ml electrolyte/mineral solution (this makes 1000 ml)

Isotonic and cereal based F-75

• cereal-based, low-osmolar F-75 (334 mOsmol/l). Replace 30 g of the

sugar with 35 g cereal flour in F-75 recipes above. Cook for 4 min.

This may be helpful for children with osmotic diarrhoea

• isotonic versions of F-75 (280 mOsmol/l) are available commercially

from Nutriset. In these, maltodextrins replace some of the sugar, andall the extra nutrients (K, Mg and micro-nutrients) are incorporated

8/12/2019 9241546093



Appendix 6

Volume of F-75 to give for children of different weights(see Appendix 7 for children with severe (+++ oedema)

a Volumes in these columns are rounded to the nearest 5 ml.b Feed 2-hourly for at least the first day. Then, when little or no vomiting, modest diarrhoea (<5 watery stools per day),

and finishing most feeds, change to 3-hourly feeds.c After a day on 3-hourly feeds: If no vomiting, less diarrhoea, and finishing most feeds, change to 4-hourly feeds.

Weight

of child

(kg)

2.02.22.42.62.83.03.23.43.63.84.04.24.44.64.85.05.25.45.65.86.06.26.4

6.66.87.07.27.47.67.88.08.28.48.68.89.09.29.49.6

9.810.0

Volume of F-75 per feed (ml)a

Every 2 hoursb

(12 feeds)

2025253030353535404045455050555555606065657070

757575808085859090909595

100100105105

110110

Every 3 hoursc

(8 feeds)

3035404545505555606065707075808085909095

100100105

110110115120120125130130135140140145145150155155

160160

Every 4 hours

(6 feeds)

45505555606570758085909095

100105110115120125130130135140

145150155160160165170175180185190195200200205210

215220

Daily total

(130 ml/kg)

260286312338364390416442468494520546572598624650676702728754780806832

858884910936962988

1014104010661092111811441170119612221248

12741300

80% of daily totala

(minimum)

210230250265290310335355375395415435460480500520540560580605625645665

685705730750770790810830855875895915935960980

1000

10201040

8/12/2019 9241546093



Appendix 7

Volume of F-75 for children with severe (+++) oedema

a Volumes in these columns are rounded to the nearest 5 ml.b Feed 2-hourly for at least the first day. Then, when little or no vomiting, modest diarrhoea (<5 watery stools per day),

and finishing most feeds, change to 3-hourly feeds.c After a day on 3-hourly feeds: If no vomiting, less diarrhoea, and finishing most feeds, change to 4-hourly feeds.

Weight with

+++ oedema

(kg)

3.03.23.43.63.84.04.24.44.64.85.05.25.45.65.86.06.26.46.66.87.07.27.47.67.8

8.08.28.48.68.89.09.29.49.69.8

10.010.210.410.610.811.0

11.211.411.611.812.0

Volume of F-75 per feed (ml)a

Every 2 hoursb

(12 feeds)

25253030303535354040404545455050505555556060606565

65707070757575808080858585909090

959595

100100

Every 3 hoursc

(8 feeds)

404045455050555560606565707075758080858590909595

100

100105105110110115115120120125125130130135135140

140145145150150

Every 4 hours

(6 feeds)

505560606565707575808585909595

100105105110115115120125125130

135135140145145150155155160165165170175175180185

185190195195200

Daily total

(100 ml/kg)

300320340360380400420440460480500520540560580600620640660680700720740760780

800820840860880900920940960980

100010201040106010801100

11201140116011801200

80% of daily

totala

(minimum)

240255270290305320335350370385400415430450465480495510530545560575590610625

640655670690705720735750770785800815830850865880

895910930945960

8/12/2019 9241546093



Appendix 8

Range of volumes for free feeding with F-100

a Volumes per feed are rounded to the nearest 5 ml.

Weight of Child

(kg)

2.02.22.42.62.8

3.03.23.43.63.84.04.24.44.64.85.05.25.45.65.86.0

6.26.46.66.87.07.27.47.67.88.08.28.48.68.89.09.29.49.69.8

10.0

Range of volumes per 4-hourly feed

of F-100 (6 feeds daily)

Range of daily volumes of F-100

Minimum

(ml)

5055606570

7580859095

100105110115120125130135140145150

155160165170175180185190195200205210215220225230235240245250

Maximum

(ml) a

75809095

105

110115125130140145155160170175185190200205215220

230235240250255265270280285295300310315325330335345350360365

Minimum

(150 ml/kg/day)

300330360390420

450480510540570600630660690720750780810840870900

930960990

10201050108011101140117012001230126012901320135013801410144014701500

Maximum

(220 ml/kg/day)

440484528572616

660704748792836880924968

10121056110011441188123212761320

13641408145214961540158816281672171617601804184818921936198020242068211221562200

8/12/2019 9241546093



Appendix 9

Weight record chartName: Sipho age 14 months, sex: male, wt on admission: 4 kg, ht: 65 cm, oedema ++

Days

8/12/2019 9241546093



Appendix 10Structured play activities

Play therapy is intended to develop language skills and motor activities

aided by simple toys. It should take place in a loving, relaxed and stimulating

environment.

Language skills

At each play session:

• teach local songs and finger and toe games

• get child to laugh and vocalise, repeat what (s)he says

• describe all activities

• teach action words with activities e.g. ‘bang bang’ as (s)he beats a

drum, ‘bye bye’ as (s)he waves etc.

• teach concepts at every opportunity, examples are in italics in the

text below

Motor activities

Encourage the child to perform the next motor milestone e.g.:

• bounce the child up and down and hold him/her under the arms so

that the feet support the child’s weight

• prop the child up, roll toys out of reach, encourage the child to crawl

after them

• hold hand and help the child to walk

• when starting to walk alone, give a ‘push-along’ and later a ‘pull-

along’ toy

Activities with toys

Simple toys can easily be made from readily available materials. These

toys can be used for a variety of different motor activities:

‘Ring on a string’

• Swing the ring within reach and tempt the child to grab it

• suspend ring over the crib and encourage the child to knock it and

make it swing

• let child explore the ring, then place it a little distance from child with

the string stretched towards him/her and within reach. Teach the child

to retrieve the ring by pulling on the string horizontally

• sit child on lap, then holding the string, lower the ring towards the

ground. Teach child to get the ring by pulling up on the string vertically.

Also teach child to dangle the ring.

8/12/2019 9241546093



‘Rattle and drum’

• Let the child explore rattle. Show child how to shake it saying ‘shake

shake’

• encourage child to shake the rattle by saying ‘shake’ but without

demonstrating

• teach child to beat drum with shaker saying ‘bang bang’

• roll drum out of reach and let child crawl after it, saying ‘fetch it’

• get child to say ‘bang bang’ as (s)he beats drum

‘In and Out’ toy with blocks

• Let the child explore blocks and container. Put blocks into container

and shake it, then teach child to take them out, one at a time, saying

‘out’ and ‘give me’

• teach the child to take out blocks by turning container upside down

• teach the child to hold a block in each hand and bang them together

• let the child put blocks in and out of container saying ‘in’ and ‘out’

• cover blocks with container saying ‘where are they, they areunder

the cover’. Let the child find them. Then hide them under two and then

three covers (e.g. pieces of cloth)

• turn the container upside down and teach the child to put blocks on

top of the container

• teach the child to stack blocks: first stack two then gradually increase

the number. Knock them down saying, ‘up up’ then ‘down’ . Make a

game of it

• line up blocks horizontally: first line up two then more; teach the child

to push them along making train or car noises. Teach older children

words such as stop and go, fast and slow and next to. After this

teach to sort blocks by colour, first two then more, and teach high and

low building. Make up games

Posting bottle

• Put an object in the bottle, shake it and teach the child to turn the

bottle upside down and to take the object out saying ‘can you get it?’

Then teach the child to put the object in and take it out. Later try with

several objects

8/12/2019 9241546093



Stacking bottle tops

• Let the child play with two bottle tops then teach the child to stack

them saying ‘I’m going to put one on top of the other’. Later, increase

the number of tops. Older children can sort tops by colour and learn

concepts such as high and low

Books

• Sit the child on your lap. Get the child to turn the pages, pat pictures

and vocalise. Later, let the child point to the picture you name. Talk

about pictures, obtain pictures of simple familiar objects, peopleand animals. Let older children name pictures and talk about them

Doll

• Teach the word ‘baby’ . Let the child love and cuddle the doll. Sing

songs whilst rocking the child

• teach the child to identify his/her own body parts and those of the doll

when you name them. Later (s)he will name them

• put the doll in a box as a bed and give sheets, teach the words ‘bed

and sleep’ and describe the games you play

8/12/2019 9241546093



Appendix 11

Discharge card

8/12/2019 9241546093



Discharge card

R e c o m m e n d a t i o

n s f o r F e e d i n g D u r i n g S i c k n e

s s a n d H e a l t h *

A g o o d d a i l y d i e t s h

o u l d b e a d e q u a t e i n q u a n t i t y a n d i n c l u d e a n e n e r g y - r i c h f o o d ( f o r e x a m p l e ,

t h i c k c e r e a l w i t h a d d e d o i l ) ; m e a t ,

f i s h , e g g s , o r p u l s e s

; a n d f r u i t s a n d v e g e t a b l e s

* T h e s e r e c o m m e n d a t i o n s

a r e c o n s i s t e n t w i t h c u r r e n t

W H O i n f a n t f e e d i n g p o l i c y .

* * T h e d e c i s i o n w h e n p r e c i s

e l y t o b e g i n c o m p l e m e n t a r y

f e e d i n g s h o u l d b e m a d e i n

c o n s u l t a t i o n w i t h a h e a l t h

w o r k e r , b a s e d o n t h e i n d i v i d u a l i n f a n t ’ s s p e c i f i c g r o w t h

a n d d e v e l o p m e n t n e e d s .

F e e d i n g

R e c o m m e n d a t i o n s f o r a C h i l d W h o H a s P E R S I S T A N T D I A R R H O E A

• I f

s t i l l b r e a s t f e e d i n g , g i v e m o r e f r e q u e n t , l o n g e r b r e

a s t f e e d s ,

d a y a n d n i g h t .

• I f

t a k i n g o t h e r m i l k :

- r e p l a c e w i t h i n c r e a s e d b r e a s t f e e d i n g O R

-

r e p l a c e w i t h f e r m e n t e d m i l k p r o d u c t s , s u c h a s y o g h u r t O R

-

r e p l a c e h a l f t h e m i l k w i t h n u t r i e n t - r i c h s e m i s o l i d

f o o d ,

• F o r o t h e r f o o d s ,

f o l l o w

f e e d i n g r e c o m m e n d a t i o n s f o

r t h e c h i l d ’ s a g e

8/12/2019 9241546093



For further information please contact:

Dr Sultana Khanum

Department of Nutrition for Health and DevelopmentWorld Health Organization

20 Avenue Appia

1211 Geneva 27, Switzerland

Telephone : +41-22-791 2624

Fax : +41-22-791 4156

Website : www.who.int

For the WHO South-East Asia Region, this publication can be obtained from:


Regional Office for South-East Asia

World Health House

Indraprastha Estate

New Delhi - 110 002, India

Telephone : 91-11-23370804

Fax : 91-11-23370197

Email : [email protected]

Otherwise:

Marketing and DisseminationWorld Health Organization

20 Avenue Appia

1211 Geneva 27, Switzerland

Telephone : +41-22-791 2476

Fax : +41-22-791 4857

Email : [email protected]

8/12/2019 9241546093


Documents

9241546093